Guardian’s Name *

Relationship to Student *

Email *

Phone *

First Name *

Last Name *

Date of birth

Select all diagnosed disabilities *

ADHD/Executive Function disorder

Autism

Specific Learning disabilities ( Dyslexia/Dysgraphia/Dyscalculia/ Auditory processing disorder/ Language processing disorder/ Nonverbal learning disabilities

Emotional Disabilities ( Opposition Defiant Disorder/Conduct Disorder)

Speech and Language

NA

Gender

Male

Female

Identify *OTHER Disabilities

School District *

School Name *

Students Grade *

Does the student have a *

IEP

504 Plan

Neither yet

Requested Services (Select all that apply) *

Virtual Attendance at IEP/504 Meetings

Student Progress Monitoring

Email Monitoring & Communication Support

Technical Assistance

Dispute Resolution Services

Case Documentation & Record Keeping

Direct Advocacy Support (for 2-3 IEP Meetings)

IEP/504 Record Review

Progress Monitoring